Section 27-21A-1


As used in this chapter, the following terms shall have the following meanings, respectively:

(1) AGENT. A person who is appointed or employed by a health maintenance organization and who engages in solicitation of membership in such organization. This definition does not include a person enrolling members on behalf of an employer, union, or other organization.

(2) BASIC HEALTH CARE SERVICES. Emergency care, inpatient hospital and physician care, and outpatient medical services.

(3) COMMISSIONER. The Commissioner of Insurance.

(4) ENROLLEE. An individual who is enrolled in a health maintenance organization.

(5) EVIDENCE OF COVERAGE. Any certificate, agreement, or contract issued to an enrollee setting out the coverage to which he is entitled.

(6) HEALTH CARE SERVICES. Any services included in the furnishing to any individual of medical or dental care, or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury, or physical disability.

(7) HEALTH MAINTENANCE ORGANIZATION. Any person that undertakes to provide or arrange for basic health care services through an organized system which combines the delivery and financing of health care to enrollees. The organization shall provide physician services directly through physician employees or under contractual arrangements with either individual physicians or a group or groups of physicians. The organization shall provide basic health care services directly or under contractual arrangements. When reasonable and appropriate, the organization may provide physician services and basic health care services through other arrangements. The organization may provide, or arrange for, health care services on a prepayment or other financial basis.

(8) INSURER. Every insurer authorized in this state to issue contracts of accident and sickness insurance. Hospital service nonprofit corporations, nonprofit medical service corporations, and nonprofit health care corporations are included within such term.

(9) PERSON. Any natural or artificial person including, but not limited to, individuals, partnerships, associations, trusts, or corporations.

(10) PROVIDER. Any physician, hospital, or other person which is licensed or otherwise authorized in this state to furnish health care services.

(11) SCHEDULE OF CHARGES. A statement of the method used by a health maintenance organization to establish rates.

(12) STATE HEALTH OFFICER. The executive officer of the State Department of Public Health.

(13) UNCOVERED EXPENDITURES. The costs of health care services that are covered by a health maintenance organization, for which an enrollee would also be liable in the event of the organization's insolvency.

(Acts 1986, No. 86-471, p. 854, §1.)